Treatment of massive and submassive Pulmonary Embolism

Approximately 3% to 5% of patients with an acute PE present

with hemodynamic compromise, defined as a systolic blood pressure

,90 mm Hg or a decrease in systolic blood pressure 40 mm Hg

from baseline

These patients are at a significantly greater risk

for mortality, as high as 50% by 90 days compared with patients

with acute PE who do not present with hemodynamic compromise.

As documented above, although thrombolytic therapy may reduce

mortality for patients with PE and hemodynamic compromise,

also associated with an increased risk for major bleeding and

intracranial bleeding. Nevertheless, because of the high risk of

mortality in this small subset of patients with PE, the ASH guideline

panel provided a strong recommendation in favor of the use of

thrombolytic therapy (the decision as to whether this should be

systemic or catheter-directed thrombolysis ). Implementation of this recommendation

depends on the ability to rapidly evaluate patients, confirm the

diagnosis of PE and associated hemodynamic compromise, and

initiate appropriate therapy.

Recommendation for submassive PE :

For patients with PE with echocardiography and/or biomarkers

compatible with right ventricular dysfunction but without he-

modynamic compromise (submassive PE),

the ASH guideline

panel suggests anticoagulation alone over the routine use of

thrombolysis in addition to anticoagulation (conditional rec-

ommendation based on low certainty in the evidence of effect).

Remarks:

Thrombolysis is reasonable to consider for younger

patients with submassive PE at low risk for bleeding. Patients

with submassive PE should be monitored closely for the

de-

velopment of hemodynamic compromise.